Osteoporosis, which literally means “porous bone”, leads to literally abnormally porous bone that is more compressible like a sponge, than dense like a brick. Osteoporosis is a disease with a very wide distribution all over the world. Osteoporosis leads to bones being porous and fragile, and the complications of this disease include fractures and delayed healing. The burdens of such global problem are immense to the health care providers due to the increasing cost of treatment and prevention, and the increasing morbidity and mortality. Although neither calcium nor vitamin D has been shown to prevent osteoporosis in postmenopausal women alone, the combination does. Both calcium and vitamin D are commonly used in the treatment of osteoporosis. The estrogens and raloxifene both prevent bone loss in postmenopausal women, and the estrogens probably also decrease the risk of first fracture. There is good evidence that raloxifene prevents further fractures in postmenopausal women who have already had fractures and some evidence that estrogen does as well. Calcitonin increases bone mineral density in early postmenopausal women and men with idiopathic osteoporosis, and also reduces the risk of new fractures in osteoporotic women. The bisphosphonate alendronate prevents bone loss and reduces fractures in healthy and osteoporotic postmenopausal women, and in osteoporotic men. Risedronate is more potent and has fewer upper gastrointestinal side effects than alendronate, and reduces the incidence of fractures in osteoporotic women. Intermittent use of the potent bisphosphonate zoledronate also increases bone mineral density and may become an alternative in the prevention and treatment of osteoporosis. All of the agents discussed above prevent bone resorption, whereas teriparatide increases bone formation and is effective in the treatment of osteoporotic women and men. In the treatment of secondary osteoporosis associated with the use of glucocorticoids to treat inflammation or prevent rejection after transplantation, the bisphosphonates are effective. The agents that have undergone some clinical trialing as new or alternative drugs for the treatment of osteoporosis include tibolone, new SERMs, androgens, growth hormone, insulin-like growth factor-1 and stontium ranelate. The targets/drugs that are being developed to inhibit bone resorption include the OPG/RANKL/RANK system, cathepsin K inhibitors, vitronectin avb3 receptor antagonists, estren, the interleukin-6 and gp130 system, cytokines and growth factors. New drugs/targets to promote bone formation include the commonly used lipid-lowering statins and the calcilytic release of parathyroid hormone (PTH).
Many international and local studies are published including those from Saudi Arabia and Arabian gulf states all agrees on the increasing risks of osteoporosis. Fractures and its complications, and the need to have more emphasis on research that leads to improvement of the strategies of prevention and treatment.
Osteoporosis is a disease in which bones become fragile and more likely to break on minimal trauma. Osteoporosis is a condition of older persons (Whitney & Rolfes, Understanding Nutrition, Ninth edition, 2002, Wadsworth Group). A World Health Organization (WHO) has defined osteoporosis as “A disease characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk” (Assessment of fracture risk and its application to screening for postmenopausal osteoporosis, Report of a WHO Study Group, World Health Organ Tech Rep Ser 1994; 843:1-129). According to this definition, the diagnosis of osteoporosis requires the presence of a fracture risk. The World Health Organization now defines osteoporosis by bone mineral density (BMD) measurement, which allows diagnosis and treatment of osteoporosis prior to incident fracture. The major complication of osteoporosis is an increase in fragility fractures leading to morbidity, mortality, and decreased quality of life. The osteoporosis process can operate silently for decades. Osteoporosis is known as the silent thief because the bone loss occurs without symptoms.
Osteoporosis is an important public health issue: Osteoporosis is a major public health threat for an estimated 44 million Americans or 55 percent of the people 50 years of age and older. Of these over 10 million people have been diagnosed as having osteoporosis (Mayes. Review of post menopausal osteoporosis pharmacology. Nutr. Clin. Prac. 2007: 22; 276 to 285). 12.5% of all Europeans over the age of 50 are likely to receive a spinal fracture of some kind in any given year. An estimated 75 million people in Europe, the United States, and Japan have osteoporosis (Who are candidates for prevention and treatment for osteoporosis?).
In the U.S. today, almost 34 million more are estimated to have low bone mass, placing them at increased risk for osteoporosis (Cashman (2007), Diet, Nutrition and Bone Health. Journal of Nutrition, Supplement: 2507S to 2512S). According to the World Health Organization, 55% of the people over the age of 50 years in the USA suffer from osteoporosis (National Osteoporosis Foundation, America's Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation, Washington D.C.: National Osteoporosis Foundation; 2002).
Hip fractures cause the most morbidity with reported mortality rates up to 20-24% in the first year after a hip fracture (Cooper C, Atkinson E J, Jacobsen S J, et al. (1993), Population-based study of survival after osteoporotic fractures, Am J Epidemiol 137:1001; Leibson C L, Tosteson A N, Gabriel S E, et al. (2002), Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study, J Am Geriatr Soc 50:1644.), and greater risk of dying may persist for at least 5 years afterwards (Magaziner J, Lydick E, Hawkes W, et al. (1997), Excess mortality attributable to hip fracture in white women aged 70 years and older, Am J Public Health 87:1630). Loss of function and independence among survivors is profound, with 40% unable to walk independently, 60% requiring assistance a year later (Magaziner J, Simonsick E M, Kashner T M, et al. (1990), Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study, J Gerontol 45:M101). Because of these losses, 33% are totally dependent or in a nursing home in the year following a hip fracture (Cooper C, Atkinson E J, Jacobsen S J, et al. (1993), Population-based study of survival after osteoporotic fractures, Am J Epidemiol 137:1001; Riggs B L and Melton L J, 3rd (1995), The worldwide problem of osteoporosis: insights afforded by epidemiology, Bone 17:505 S; Kannus P, Parkkari J, Niemi S and Palvanen M (1996), Epidemiology of osteoporotic ankle fractures in elderly persons in Finland. Ann Intern Med 125:975).
In Asia it is projected that more than about 50% of all osteoporotic hip fractures will occur in Asia by the year 2050 (Gullberg B, Johnell O and Kanis J A (1997), World-wide projections for hip fracture, Osteoporos Int 7:407. & Cooper C, Campion G and Melton L J, 3rd (1992), Hip fractures in the elderly: a world-wide projection. Osteoporos Int 2:285).
Iran accounts for 0.85% of the global burden of hip fracture and 12.4% of the burden of hip fracture in the Middle East (madi-Abhari S, Moayyeri A and Abolhassani F (2007), Burden of hip fracture in Iran. Calcif Tissue Int 80:147). In Hong Kong in 1996, the acute hospital care cost of hip fracture per year amounted to $17 million (Lau E M (2001), Epidemiology of osteoporosis, Best Pract Res Clin Rheumatol 15:335). For India, expert groups peg the number of osteoporosis patients at approximately 26 million (2003 figures) with the numbers projected to increase to 36 million by 2013 (Osteoporosis Society of India (2003), Action Plan Osteoporosis: Consensus statement of an expert group, New Delhi). In a study among Indian women aged 30-60 years from low income groups, BMD at all the skeletal sites were much lower than values reported from developed countries, with a high prevalence of osteopenia (52%) and osteoporosis (29%) thought to be due to inadequate nutrition (Shatrugna V, Kulkarni B, Kumar P A, et al. (2005), Bone status of Indian women from a low-income group and its relationship to the nutritional status, Osteoporos Int 16:1827). In Japan, new hip fractures increased a dramatic 1.7-fold in the 10 years from 1987 to 1997 (Rowe S M (2003), An epidemiological study of hip fracture: a comparison between 1991 and 2001, Korean J Bone Metab 10:109). In Korea, the occurrence of hip fractures increased about 4-fold over 10 years (1991-2001) (Rowe S M (2003), An epidemiological study of hip fracture: a comparison between 1991 and 2001, Korean J Bone Metab 10:109).
In Saudi Arabia in 52% of examined Saudi Arabian females for example, vitamin D level was extremely low (because of clothes that block almost all sunlight), but their bones were not affected (Ghannam N N, et al, Bone mineral density of the spine and femur in healthy Saudi females: relation to vitamin D status, pregnancy, and lactation, Calcif Tissue Int 1999 July; 65(1):23-8). In Saudi Arabia with a population of 1,461,401 persons aged 50 years or more, 8,768 would suffer femoral fractures yearly at a cost of $1.14 billion (Bubshait D and Sadat-Ali M (2007), Economic implications of osteoporosis-related femoral fractures in Saudi Arabian society. Calcif Tissue Int 81:455). A study that was conducted in the eastern region of Saudi Arabia concluded that the incidence of PMO in Saudi Arabian women is reportedly higher in comparison to women in Western countries (Sadat-Ali M, Al-Habdan I, Al-Mulhim F A, El-Hassan A Y, Effect of parity on bone mineral density among postmenopausal Saudi Arabian women, Saudi Med J 2005; 26: 1588-90; El-Desouki M. Bone mineral density of the spine and femur in the normal Saudi population, Saudi Med J 1995; 16: 30-35). Another report in the eastern region of Saudi Arabia indicates that the incidence of postmenopausal osteoporosis (PMO) of 30% to 40% with over 60% having some degree of osteopenia (Mir Sadat-Ali, AbdulMohsen AlElq., Osteoporosis among male Saudi Arabs: a pilot study, Ann Saudi Med 2006; 26(6):450-454). In a prospective study of the prevalence of male osteoporosis among Saudi Arabs, the prevalence of osteoporosis among males was higher than Western males (Mir Sadat-Ali, AbdulMohsen AlElq., Osteoporosis among male Saudi Arabs: a pilot study, Ann Saudi Med 2006; 26(6):450-454). A study conducted in the central region of Saudi Arabia reported that healthy men have low bone mineral density, and the lumbar spine appears to be affected to a higher degree. Possible underlying causes include nutritional, life style and genetic factors (EL-DESOUKI Mahmoud; SULIMANI Riad A.; High prevalence of osteoporosis in Saudi men. Saudi medical journal, ISSN 0379-5284 2007, vol. 28, no. 5, pp. 774-777). More studies are needed to determine the national prevalence of male osteoporosis. It is recommended that serious measures to be undertaken to prevent male osteoporosis to stop any future epidemic of catastrophic osteoporosis-related fractures.
Osteoporosis has high prevalence in women; 1 in 3 women older than 50 years will eventually experience osteoporotic fractures, as will 1 in 5 men according to (International Osteoporosis Foundation, Facts and statistics about osteoporosis and its impact). Current Management of Fracture in osteoporosis is not different than that of standard fracture management in patients with normal bone density. It is thus mandatory to look at the fracture management of osteoporosis patients in a revolutionary manner owing to the poor and delayed healing of fractures in this wide spread disorder. Osteofragility fractures occur in men due to a compromise in bone strength, coupled with either trauma or a fall. In men at least 65 years of age, osteoporosis can be defined as bone mineral density (at the proximal femur, spine or distal forearm) of 2.5 standard deviations or less below the mean for a normal young adult man, using a male reference database (i.e., T-score value of ≦−2.5). In men 50-65 years of age, a similar definition is used if other risk factors for a fracture are present. Osteoporosis is increasingly recognized in men. One in three men aged >60 years will suffer an osteoporotic fracture. Spinal fractures occur in 5% of men (compared with 16% of women) and hip fractures in 6% of men (compared with 18% of women) >50 years of age. The risk of hip fracture increases by 2.6-fold for each standard deviation decrease in bone density measured at the hip. At present, the life expectancy for men has increased to a mean age of 76.8 years. With men now living longer, they can be expected to develop multiple coexisting illnesses contributing to bone loss and an increased likelihood of falling and fragility fractures. It is estimated that 30-60% of men presenting with spinal fractures have another illness contributing to their bone disease. The ideal therapy for men with osteoporosis should include an intervention which significantly increases bone strength and reduces fracture rates, is safe, easy to administer and economical.